Basic Information
| Provider Information | |||||||||
| NPI: | 1417083064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | OMAR | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 W 1200 N | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840572948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012265565 | ||||||||
| FaxNumber: | 8012265565 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 E 9000 S | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840702201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015619839 | ||||||||
| FaxNumber: | 8013520027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 346435-2401 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT00010324 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.